Abstract
Secondary bone grafting from the iliac crest is the gold standard in the reconstruction of maxillary alveolar bone defects in cleft patients. Numerous techniques for this graft have been described, although none is considered clearly superior at this time. A retrospective chart study was performed of 72 alveolar clefts in 59 patients who underwent an alveolar iliac crest bone graft with nasal floor reconstruction, with or without concomitant secondary cheilorhinoplasty. Forty-four patients were included in the bone grafting group and 15 in the concomitant cheilorhinoplasty group. Both groups had a sulcular translation mucoperiosteal flap with anterior repositioning of the gingival papilla as the preferred intraoral flap technique. One-third of patients had undergone previous attempts at oronasal fistula closure. Results showed 100% Bergland stage 1 in the cheilorhinoplasty group and 96% in the bone graft group. Two failures (stage 4) were observed in the bone graft group. The infection rate was 9% in the cheilorhinoplasty group and 2% in the bone graft group. Of clefts in the bone graft group, 10% showed postoperative residual fistulas; none were observed in the cheilorhinoplasty group. The sulcular translation flap is a simple surgical approach and shows a low complication rate.
Secondary alveolar bone grafting in the cleft patient population is a surgical technique that is well defined in the current literature. In fact, 75% of patients with a labial cleft will present an alveolar defect. This defect is characterized by a three-dimensional inverted pyramid: the nasal floor and nasal mucosa represent the superior portion and the palatal and gingival mucosae form the laterals walls.
Different goals can be achieved with secondary bone grafting, such as the closure of vestibular or palatal fistulas, achieving periodontal health and integrity, maxillary continuity and stability, which allow nasal, alar base, and labial support and subsequent orthodontic movement. Such alveolar cleft continuity may be achieved with an iliac crest bone graft, which was described by Boyne and Sands in 1972. During alveolar grafting, the presence of an incompetent orbicular or a large vestibular fistula needs to be addressed with a concomitant cheilorhinoplasty. Preoperative orbicularis oris dysfunction or large vestibular fistulas are attendant problems that can complicate gingival closure and lead to postoperative complications.
Many surgical techniques are described to access an alveolar cleft defect at the time of bone grafting. Various studies have shown the impact of soft tissue covering and mobilization without tension during secondary bone grafting, allowing good functional and aesthetic results. Decision-making related to the selection of the gingival approach has become a primary step in alveolar bone defect correction to ensure long-term success. The mucoperiosteal rotational finger flap, buccal flap with Z-plasty, vestibular flap, and translational sulcular flap are described in the literature. There is still no consensus regarding the best gingival approach and none has yet become the surgical gold standard. The finger flap involves rotation of the free gingiva without the attached gingiva and may lead to periodontal complications and a reduction in the depth of the vestibule. Multiple cleft teams favour the translational sulcular flap. This gingival approach involves a sulcular incision with a distal releasing incision on the cleft side. After alveolar cleft repair and bone graft insertion, the gingival papilla is transpositioned anteriorly allowing tension-free closure with better quality of soft tissue and bone graft coverage. Additionally, the Z-plasty flap is often considered for large alveolar defects ( Fig. 1 ). It allows flap lengthening and greater mobilization. Regardless of the surgical approach that is chosen, gingival recession remains a common complication, which can be prevented by adequate flap selection and sufficient flap mobilization.
Furthermore, postoperative radiological evaluation after alveolar cleft correction is controversial. No consensus has been established regarding the gold standard radiological evaluation. Bergland et al. and Enemark et al. described the two-dimensional evaluation of the alveolar cleft after bone grafting and classified radiological bone filling into four different stages depending on the alveolar bony fill obtained for the adjacent teeth ( Table 1 ). Stages 1 and 2 represent a successful outcome, permitting prosthodontic rehabilitation with minimal alveolar, aesthetic, and functional discrepancies. Bone graft failures occur in 2.7–5% of cases based on these studies.
| Stage 1 | Complete alveolar bone filling obtained |
| Stage 2 | More than three quarters of alveolar bone filling obtained |
| Stage 3 | Less than three quarters of alveolar bone filling obtained |
| Stage 4 | Absence of bone in alveolar cleft |
The aim of this study was to demonstrate the efficacy of the sulcular translation gingival flap and concomitant bone grafting in the treatment of alveolar clefts that have been treated with multiple previous surgeries, which may complicate an alveolar graft.
Materials and methods
Study design and sample
A retrospective chart review was performed of all patients who underwent secondary alveolar bone grafting with a sulcular translation flap, with or without secondary functional cheilorhinoplasty, between March 2004 and December 2009. Patients younger than 18 years of age with a clinically and radiologically confirmed alveolar bone defect were included in this study. Patients with unilateral and bilateral alveolar clefts were enrolled. Furthermore, an adequately documented chart was required. Bilateral alveolar defects were grafted in two stages with a 6-month interval in order to respect premaxilla vascularization and to have sufficient gingival tissue to correct vestibular and palatal fistulas. In these bilateral defect cases, because the surgery was performed in two stages, each was considered as a single unilateral case and the data collected for each stage separately. Syndromic patients and patients who had undergone previous alveolar bone grafting in the defect area were excluded from the study.
All patients enrolled in this retrospective study had an anteromedial iliac crest bone graft harvested with preservation of the cartilaginous cap. Two different groups of patients were studied. Patients in the first group were treated with bone grafting alone and those in the second group underwent simultaneous lip and nose correction in addition to the bone graft procedure. Patients with preoperative orbicularis oris muscle discontinuity with muscle diastasis confirmed during lip movement and those who had large vestibular fistulas underwent concomitant functional cheilorhinoplasty. The intraoral sulcular translation flap approach was the same in both groups.
This study was approved by the Research Ethics Board of the Centre Hospitalier Universitaire de Québec as phase 1 of a multi-phase project assessing novel therapies for cleft patients.
Study variables
Demographic information, including age at bone graft, gender, and cleft description and localization, were recorded. Data regarding previous surgical fistula correction and the presence and localization of oronasal fistulas at surgery were also noted. Orbicularis oris function and continuity was evaluated preoperatively and compared postoperatively with different lip movement.
Panoramic radiographs were obtained with the same unit. Alveolar clefts were evaluated both preoperatively and postoperatively for each individual included in the study. Panoramic radiographs were taken at the initial consultation and at 3 months postoperatively. Anatomical characteristics of the alveolar cleft and its reconstruction were evaluated using the classification of Bergland et al. at 3 months postoperatively. This classification evaluates alveolar bone filling following alveolar grafting; four stages are described ( Table 1 ). In the literature, stages 3 and 4 are considered bone graft failure. The radiological evaluator was unaware of whether or not the patient had undergone a concomitant cheilorhinoplasty.
Postoperative follow-up appointments to evaluate the sulcular translation flap and postoperative complications were scheduled at 2 weeks, 4 weeks, and 3 months. Postoperative intraoral complications were all documented, such as the development of infection, flap dehiscence, oronasal fistula recurrence, and graft failure.
Surgical techniques
Surgeries were performed in the same fashion by either of two oral and maxillofacial surgeons specializing in the paediatric maxillofacial and cleft population. Only one of these surgeons performed the concomitant functional cheilorhinoplasty. The surgical approaches were first described and explained to the patient’s family. After consent to the procedures was obtained, the patient was scheduled for surgery.
Preoperative antibiotic coverage with cefazolin was given to all patients. Regarding the iliac crest region, the inner table of the iliac crest was harvested with a 4-cm incision. An anterior and median approach with preservation of the cartilaginous cap was achieved to ensure normal growth.
In the oral cavity, a buccal sulcular incision from the cleft defect to the first molar on the cleft side was performed with a 1-cm distal 45-degree gingival releasing incision ( Fig. 2 ).
A buccal sulcular incision was performed in the contralateral anterior maxillary region. A fistulectomy was performed whenever a vestibular or palatal fistula was present. Labial vertical incisions followed the contour of the alveolar cleft and followed the vestibular fistula edges if present, without modifying the sulcular incision pattern. A full-thickness mucoperiosteal vestibular flap was raised bilaterally. In the palatal region, a sulcular incision was made from first molar to first molar. If a fistula was present in the anterior palate, an incision was performed following the fistula edges. No counter-incision was made on the palatal mucosa. Palatal, nasal, and alveolar tissues were identified and dissected. Next, the nasal and palatal mucosae were closed tightly ( Fig. 3 ). The nasal floor was reconstructed with iliac cortical bone. This cortical bone was sandwiched between the nasal mucosal repair and the corticocancellous particulate bone graft around the piriform aperture to reconstruct the nasal floor by gaining more support ( Fig. 4 ). A periosteal releasing incision was made on the malar buttress to ensure more mobility and tension-free closure of the flap. The sulcular gingival flap was then translated one tooth medially with gingival papilla transposition to close the defect tightly and without tension. The distal region was left exposed to heal by secondary intention in the first molar area on the cleft side ( Fig. 5 ).
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